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BUILDING DIVISION PERMIT
CONTRACT�ORwyTNFORMATION�
BUILDING ADDRESS:
SUITABLE CONSTRUCTION
PERMIT NO.
04080083
1601 TA.MRS TOWN IDR
OWNER'S NAME:
PERMrT LSUE DATE
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SANITARY OL N0.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG EIFCT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby alarm that 1 am IimrdN under Provisions of Chapter 9 (cammcllcing
with SodoI]0(o)of Division fdlc Burin tl Professinv Codc•and mylicermis
fall P.pp�t S �/
REVISION --DRAIN
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G°"Ram°
NO NEW PERMIT ISSUED/ORIG. #03070133
A pseers )ECu
I undersand my planxefi.11 k used u puES Ards
Licensed Profcaiond
DECLARATION
OWNER -BUILDER
I hereny afford that 1 Am exempt from the CamacIOe3 License taw for Ills
following mason. (Section 7031.5. Business and Pofaalom Code: Any city or county
which rectums A penob m wreard , alms, improve, dcmAlish, Or repair any summa
,star m I. issuance. at. oxmiRr the APPlieam fill such Permit to Ble A 111 -did -raw--'
lJavc law(ChapmrY
Sq. Ft. Floor Area
'
�(7, luation
Nal he is liccnscd pursuanuolhe provisions of the Conuomr's
(commencing with Section 7") M Division 3 of flee Business and Proressions Culc) or
��
Nn W u exempt th.mfrom and the btu for the alleged exemption. My violation of
APN Number
Oeeupan Type
Schon 7031.3 by my applicant for a permit objects Nc applicant m a civil penalty of
not mart man Ove hundred dollars ($5011).
❑ I,aowner of lM1e Pmpeny, fir my employcu with mgeru their tele compenadon,
6610098.00 Required Inspections
P
will do dee work and did swcmre is namimm�ded aro@red for side 7044, Business
and Professim" Cod.: The Conuaemrs License Law does not apply m an awmr, of
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Propriety who builds or improves thexam. and who does such work himalf fir through his
awn employees, provided thatsmh improvements Am not intended oroRemA for Ade. IL
however, the building or improvement is old widen am year of completion, me owner-
.
builder will have the burden of proving than he did not build or improve for Puryme of
ale.).
D 1, As owmr of the property, am exclusively controlling with licensed mna-materi to
construct dee pmjem (Sec. 7044. Business and Professions Cade:) The Conuacmr's U.
card. taw docs mupid, man owner of l odray who Wilds fir improves them.., and
who contracts for such pmjecu with a co rbacdm(s) licensed pursuant m Ihe Conerotmes
License La .
D l am exempt under Sea .B&PC for Nu reason
Owner Dad
WORKERS COMPENSATION DECLARATION
1 hereby allure under modify of peljuO om of rhe following declaratiorm:
'
have °rad will miles. ACenifdcate of Canons m selGinsum for WorkersCompen-
calion, As provided for by Section 37M of the labor Cod., for the performand, of Ihe
work far which this permit is issued.
D 1 have and will maimain Workers CompemNon I.... As mquiad by Section
3700 of thc labor Cade, fm the perfun ams of rhe work for which Nis permit is is mil.
My Workers Cc eniati Insuranm tamer Policy numk me
CA licy No.:
CERTIFICATE OF EX PTION FRO RK S'
COMPENSATION INSURANCE
This a<It.. Arad not W completed if the permit it fmomhundrod did. ($100)
or leu)
1 certify that in the performance of the work for which Nis permit is issued• 1 shall not
employ any person in any mannerso As m become objects. th. Workers Compenadon
Lawa of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Cemlicare of Exemption, you should
become aubjeo m the Wo&ei a Compensation provisions of the labor Code, you mum
faMwOh comply with much provisions or Nis permit shill k deemed mvel ed.
LENDING AGENCY
'
I hereby mnrm slut Vert is a eomtruclion lending agency rot the performance of
Ibe walk fur which this permit's issued (Sec. 3097. Civ. C.)
Nam,
Le"dere, Add.
1 artily than 1 have mad this application and sus thus d a above information is
context. l ago. be comply with all city and county ominamxs and sum laws mlating to
building construction. and hereby authmin r.prcmmativet of this city m enter upon th.
.hove -mentioned property rat Inspection purposes
(We) ogre. m ave, I"demnily and keep leareal.rs the City of Colombo against
liabilities, judgments, costs and expenses which may in any way accrue against aid City
r
in canagmnec of the granting of this Permit
" APPLICANT UN NDS AND W L COMP H ALL NON- INT
Issued by: Date
S UR ATIONS. �1
Re -roofs
Type ROOF
IpUddfm of Appli,arvoCced.cm, D
HAZARDOUS MATERIALS DISCLOSURE
Of
Will the applicant ar future building accupant mom or "out haermlous material
As defined by Ik Cupertino Municipal Code. Chapter 9.12. and the Health and Safety
Cate. section 25532(a)7
All roofs shall be inspected prior to any roofing material being installed.
❑Yes
If a roof is installed without first obtaining an inspection, I agree to remove
the applicant-or'future building Occupant use equipment or devices which
pWill
I hazardous air contaminants as defined by dm Bay Area Air Quality Management
all new materials for inspection.
i.ie17
Dy"
IhavereadtW rdnusm iialsmquimm.nuundcr Chapter SoftheGallfor-
nufkalb&SofctyCah.Scctioru23505.25533am125534. I undo hose Wilding
doer no, cuncnlly have 4 Ned It rs ibility m the mcupanl of We
upanc
Date
m immen mam,Am''or
nature of Applicant
/
All roof coverings to be Class "B" or better
ser authorised egcnt ,m